3.2. Discusión de Resultados
3.2.6. Caudales de diseño
Parents: The family must have been on MaineCare. If parents then lose it because their income goes over 105%, the parents are eligible for either 6 or 12 months of transitional MaineCare. After the first 6 month extension, the parents can get another 6 months of transitional MaineCare if family income is still below 185% FPL. If family income is between 185% and 213%, parents are not eligible for the second 6 months of transitional MaineCare, but children can get low-cost MaineCare or CHIP.
Children: If family income is below 163%, children may remain on free MaineCare even if the parents lose it. If the family income is between 163%-213% FPL, the family will pay a premium for coverage for their children (CHIP). If income goes above 213% FPL, the child(ren)’s eligibility will continue for the rest of the 12-month eligibility period.
For Children Only: the Health Insurance Premium Option:
If children age 18 and younger are no longer eligible to get MaineCare because their family income exceeds the limits, the family can choose to pay to continue coverage for the children for up to 18 more months under the Health Insurance Premium Option (HIPO). The cost is $250 per month per child. For more information, call the Payment Accuracy Team at toll-free 1-800-442-6003. If you are deaf or hard of hearing and have a TTY machine, call 1-800-606-0215.
Purchasing Affordable Insurance on the Federal Health Insurance Marketplace:
If parents, children, or the family do not qualify for any of the options above, they may qualify for lower costs on monthly premiums or out-of-pocket costs reductions for insurance they buy at the Health Insurance Marketplace or www.healthcare.gov. Individuals and families with income between 100-400% FPL may qualify.Losing MaineCare opens up a special enrollment period, so families and individuals can sign up outside of the Marketplaces open enrollment. This special enrollment period lasts 60 days before and 60 days after the loss of other coverage.
To learn more, visit www.healthcare.gov. To find local help, visit enroll207.com, or call Consumers for Affordable Health Care at 1-800-965-7476.
MaineCare Deductibles or Spend downs
This category of MaineCare is called ―Medically Needy.‖ Those who are over income in certain MaineCare categories or ―Categorically Needy‖ MaineCare, may be eligible in the ―Medically Needy‖ category. Seniors (at least 65), parents of minors at home or people who are blind or disabled may apply in the Medically Needy category.
In this category, a math formula is used to calculate a deductible, which is still sometimes called a ―spend-down.‖ The deductible is usually recalculated every six months. But deductibles can be retroactive for up to three months also.
Steps:
1. Verify the applicant is either a senior, blind, disabled or a parent with at least one minor at home at least half the time, but over income for that category.
2. Verify applicant meets ―Countable‖ asset guidelines for Medically Needy.
Medically Needy “Countable” Asset Limits
Family - Related SSI - Related
1 person no asset test $2000
2 people No asset test $3000
Each additional person No asset test NA
3. Subtract the Protected Income Level or PIL for the appropriate assistance unit size from countable income.
Unit Size Protected Income Level
1 $315
2 $341
3 $458
4 $575
For larger households see MaineCare Eligibility Manual Chart 5
4. Multiply the remaining amount by 6 for a prospective deductible or by 1, 2 or 3 for a retroactive deductible of 1, 2 or 3 months.
Important Tips & Info:
Write across the front page of the application, ―Consider for a spend down.‖ DHHS eligibility workers calculate deductibles. The information in this section is
for your understanding of the process.
Bills can only be counted once and must be unpaid to count toward the deductible.
The free care law requires hospitals to investigate other potential coverage by any other third party, including Medicaid, before granting free care; thus the
deductible should always be applied through DHHS before granting free care. Once a bill is written off to free care, it can’t count toward a deductible.
Bills can be old as long as they haven’t been used for a prior deductible or written off to free or charity care. If the bill has already gone to collections this may also present a problem.
Medical debt, including old bills, can be split up and used in different time-frame deductibles.
Bills must be submitted within a year of the MaineCare application date to be covered in the Medically Needy category.
Medical costs of any member of the MaineCare household, may be applied to the deductible, including transportation, insurance premiums or costs not coverable by MaineCare such as for eye glasses..
If a person gets a retrospective AND prospective deductible, they are distinctly separate eligibility periods.
To qualify for a MaineCare deductible, medical expenses must equal or exceed the amount their income exceeds the Medicaid limit.
DHHS is supposed to respond to spend down applications in ten days. Advocates may request a fair hearing after that time.
Example:
The income guideline for disability MaineCare for a household of 1 is $990 a month. Rob’s countable income (after his disregards totaling $75) is $1100. Subtract the PIL for a HH of 1 from his income: 1100 – 315 = $785. He will get a 6 month deductible amount of $785 times 6 or $4710.